These images demonstrate a distal femoral shaft fracture occurring from blunt trauma.Before performing antegrade femoral nailing, a high-qualityAP radiograph of the hip is necessary to rule out occultfemoral neck fracture.Many patients with femoral shaft injuries have CT scans performedto rule out intraabdominal injury. The CT scan cuts through thefemoral neck should also be reviewed to rule out fracture.Lateral decubitus position is preferred for antegrade femoralnailing in the patient with normal pulmonary status and nospine or pelvic injury. The affected leg is flexed, exposing the piriformis fossa without steric interference from the patients torso.The downside leg is well supported and padded to avoid neuropraxia. The surgeon is pointing to the starting point for the piriformis entry point.View of the area that is prepped out for performing the nailing.PIRIFORMISFOSSAThe piriformis fossa entry portal is directly in line with the canalof the shaft. However, it is slightly posterior to the femoral neck.It is curvilinear and angled posteriorly.Because the piriformis entry portal is on a sloped surface, astraight awl must be introduced first at an angle to the femoralshaft directly anteriorly12and then as its introduced, the hand is raised up togo in line with the femoral shaft.1cmThe skin incision, which can be approximately 1 to 1-1/2cm in length, should be made at a distance away from the piriformis fossa to allow for direct entry into the fossa. This can be best estimated by looking1cmat the AP radiograph to determine how proximal the incisionneeds to be with respect to the trochanter. The heavier thepatient, the more proximal in the buttocks the incision needs tobe in order to be in line with the femoral shaft.The fascia of the Tensor fascia Lata muscle is divided, exposing some of the musculature. The perfect lateral radiograph of the hip demonstrates theneck to be colinear with the shaft and slightly anterior to it.The piriformis fossa is easier visualized.The straight awl is introduced through the incision, thengently placed against the piriformis fossa directed anteriorly.The awl is introduced into the femoral canal; as it entersthe bone, the awl is adjusted to be in line with the femoralshaft by moving the hand and awl anteriorly.The awl is introduced into the femoral canal; as it entersthe bone, the awl is adjusted to be in line with the femoralshaft by moving the hand and awl anteriorly.Once the awl has been introduced gently, it is tappeddown past the calcar to allow for easy passage of theguidewire.Once the awl has been introduced gently, it is tappeddown past the calcar to allow for easy passage of theguidewire.The guidewire should have a gentle distal bend to allow easy passage across the fracture site. The guidewire is introduced down the femoral shaft.A soft tissue protector can be used to minimize muscle injury proximally.The guidewire is advanced down the canal. Note the colinearity of the entry point with the center of the shaft.The guidewire is introduced to the level of the fracture.The fracture is reduced and the guidewire is passed across and distally until it is just shy of the epiphyseal scar in the center of the femur on the AP radiograph. This is particularly important for distal fractures.Once the guidewire is fully introduced, length may bemeasured in many ways. While some systems havejigs to measure length, a foolproof system is to measure a residual of a guidewire of the same length.The above image demonstrates a second guidewire of thesame length introduced to the level of the trochanter.A Kocher clamp is placed on the guidewire so that the residual can be directly measured.Measuring the residual from this guidewire will give an exact measurement of the longest nail that is possible for this patient. After measurement is obtained, the femoral canal is reamed.The reamer introduced through the stab incision and the soft-tissue protector used to protect the musculature.After reaming is complete, the appropriate size nail is chosen.Before the nail is inserted, as with any nailing procedure, theproximal jig needs to be checked for appropriate alignment ofthe locking mechanism.An exchange tube is placed over the ball-tip guidewire, which is then removed. A straight guidewire is then placed through the exchange tube, which is then removed,allowing for placement of the nail over the straight guidewire.The nail is gently tapped down the canal. Any significantresistance warrants biplanar radiographic confirmation ofappropriate position of both the guidewire and the nail, aswell as areas of the femoral neck for possible fracture.After the nail is appropriately seated, with the jig at thelevel of the greater trochanter, the proximal jig is used tolock the nail. Distal locking is generally performed using a freehand technique via perfect circles.The above image demonstrates the C-arm in a position to view a perfect circle.This image shows the distal end of the nail with thescrews in place, the blackout radiograph.AP and lateral radiographs of the nail in place.Portable AP x-ray of the hip, which should be taken in the operating room to rule out iatrogenic femoral neck fracture.